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Interventions for Feeding and Nutrition in Cerebral Palsy
Comparative Effectiveness Reviews, No. 94
Authors
Investigators: Elizabeth D Ferluga, MD, Kristin R Archer, PhD, DPT, Nila A Sathe, MA, MLIS, Shanthi Krishnaswami, MBBS, MPH, Andrea Klint, RD, Mary Lou Lindegren, MD, and Melissa L McPheeters, PhD, MPH.Affiliations
Structured Abstract
Objectives:
The Vanderbilt Evidence-based Practice Center examined the effects of available interventions for feeding and nutrition problems that have been evaluated in individuals with cerebral palsy (CP).
Data sources:
MEDLINE® via the PubMed® interface, PsycINFO® (psychology and psychiatry literature), the Educational Resources Information Clearinghousesm, OTSeeker, REHABDATA, and the Cumulative Index of Nursing and Allied Health Literature (CINAHL®) database. Additional studies were identified from reference lists and technical experts.
Review methods:
We reviewed studies providing effectiveness data for feeding interventions in populations of any age with CP. We included studies focused on nonsurgical and surgical interventions for feeding and nutrition difficulties. Nonsurgical interventions included positioning, oral appliances, oral stimulation, sensorimotor facilitation, and caregiver training. Surgical interventions included gastrostomy or jejunostomy tubes and fundoplication. We assessed both intermediate/surrogate and patient-centered/health outcomes.
Results:
Fifteen articles (comprising 13 unique studies) met our inclusion criteria. One good quality systematic review on behavioral interventions for feeding issues in individuals with cerebral palsy was published in 2011 and is updated with one additional study on caregiver education in this review. The existing review included 21 studies with conflicting results related to the effects of sensorimotor interventions on short-term improvements in feeding. Eleven studies (nine case series) of surgical interventions met our inclusion criteria. These studies included 309 children. In all nine studies of gastrostomy (with or without fundoplication), gastrostomy-fed children gained weight. Baseline weight z-scores ranged from −3.56 to −0.39; followup z-scores ranged from −2.63 to −0.33, relative to typically developing populations. Two studies assessed fundoplication for reflux: in one RCT both Nissen fundoplication and vertical gastric plication reduced reflux (reduction in symptoms of 57% and 43%, respectively), while in one case series, reflux recurred within 12-months postfundoplication in 30 percent of children. The highest rates of reported harms in any study were minor site infection (59%), formation of granulation tissue (42%), gastric leakage, recurrent reflux (30%), and aspiration and pneumonia (29%). Even though the reported death rates ranged from 7 percent to 29 percent, the underlying cause of death was most likely not due to the surgical treatment.
Conclusions:
Evidence for behavioral interventions for feeding disorders in CP consists of mostly small, short-term, pre-post studies, with strength of evidence ranging from insufficient to moderate. Some studies suggest that interventions such as oral appliances may enhance oral sensorimotor skills, but there is a clear need for rigorous, comparative studies. Evidence for surgical interventions is insufficient to low. All studies to date demonstrate significant weight gain with gastrostomy. Results for other growth measures are mixed, and substantial numbers of children remained underweight, although given a lack of appropriate reference standards for the CP population, these results should be interpreted cautiously. Longer term, comprehensive case series are needed, as are prospective cohort studies. More research is needed to understand potential harms in the context of benefits and potential risks of not treating.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Results of Literature Searches and Description of Included Studies
- Key Question 1a Compared with other nonsurgical interventions or no intervention, how effective are behavioral interventions, including positioning, oral appliances, oral stimulation, sensorimotor facilitation, and caregiver training, for improving nutritional state/growth, health outcomes and health care/resource utilization, and quality of life in individuals with cerebral palsy and feeding difficulties?
- Key Question 1b Is the effectiveness of behavioral interventions modified by age, race, severity, functional status (e.g. GMFCS level), or initial nutritional status?
- Key Question 2a Compared with other nonsurgical interventions or no intervention, how effective are nutritional interventions (food thickeners, caloric supplementation with formulas, vitamin supplementation, and altering food consistency (e.g. pureeing)), for improving nutritional state/ growth, health outcomes and health care/resource utilization, and quality of life in individuals with cerebral palsy and feeding difficulties?
- Key Question 2b Is the effectiveness of nutritional interventions modified by age, race, severity, functional status (e.g. GMFCS level), or initial nutritional status?
- Key Question 3a What is the comparative effectiveness of tube feeding compared with oral feeding or to nutritional and behavioral interventions in individuals with cerebral palsy who present with feeding difficulties, including malnourishment, failure to thrive, aspiration and excessive caregiver burden?
- Key Question 3b Among individuals with cerebral palsy and feeding difficulties with significant reflux, what is the effectiveness of g-tube placement with fundoplication versus oral feeding for reducing reflux and for improving nutritional state/ growth, health outcomes and health care/resource utilization, and quality of life?
- Key Question 3c Among individuals who develop reflux following gastrostomy, what is the comparative effectiveness of j-tube versus fundoplication for reducing reflux in the short term and achieving improvements in nutritional state/ growth, health outcomes and health care/resource utilization, and quality of life?
- Key Question 3d Is the effectiveness of tube feeding modified by tube placement, age, race, severity, functional status (e.g. GMFCS level), initial nutritional status, or continuous v bolus feeding?
- Grey Literature
- Discussion
- References
- Acronyms/Abbreviations/Symbols
- Glossary
- Appendix A Search Strategies
- Appendix B Data Extraction Forms
- Appendix C Evidence Table
- Appendix D Tools Used To Assess the Quality of the Literature
- Appendix E Quality of the Literature
- Appendix F Excluded Studies
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10065-I. Prepared by: Vanderbilt Evidence-based Practice Center, Nashville, TN
Suggested citation:
Ferluga ED, Archer KR, Sathe NA, Krishnaswami S, Klint A, Lindegren ML, McPheeters ML. Interventions for Feeding and Nutrition in Cerebral Palsy. Comparative Effectiveness Review No. 94. (Prepared by the Vanderbilt Evidence-based Practice Center under Contract No. 290-2007-10065-I) AHRQ Publication No. 13-EHC015-EF. Rockville, MD: Agency for Healthcare Research and Quality. March 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Vanderbilt Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10065-I). The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help clinicians, employers, policymakers, and others make informed decisions about the provision of health care services. This report is intended as a reference and not as a substitute for clinical judgment.
This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products or actions may not be stated or implied.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
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